From the Guidelines
Elevated parathyroid hormone (PTH) levels should be treated with surgical parathyroidectomy, specifically total parathyroidectomy (TPTX), as it has been shown to be effective in reducing PTH levels and alleviating symptoms in patients with secondary hyperparathyroidism due to chronic kidney disease, as supported by the most recent study 1.
Treatment Options
The treatment of elevated PTH levels depends on the underlying cause, with primary hyperparathyroidism typically requiring surgical removal of the overactive parathyroid gland(s) and secondary hyperparathyroidism requiring addressing the underlying cause, such as kidney disease or vitamin D deficiency.
- Medical therapy, including vitamin D supplementation (typically 1,000-2,000 IU daily of vitamin D3) and calcium supplements (500-1,000 mg daily), may be effective in controlling PTH levels in some cases, as noted in 1.
- Phosphate binders like sevelamer and calcimimetics such as cinacalcet (starting at 30 mg daily) may also be used to lower PTH levels in patients with kidney disease.
Lifestyle Modifications
Lifestyle modifications, including:
- Adequate hydration
- Weight-bearing exercise
- Limiting phosphate-rich processed foods
- Avoiding excessive calcium intake can help manage elevated PTH levels and prevent complications.
Monitoring
Regular monitoring of calcium, vitamin D, and PTH levels is necessary to assess treatment effectiveness, as emphasized in 1 and 1.
Surgical Intervention
Surgical parathyroidectomy, specifically TPTX, has been shown to be effective in reducing PTH levels and alleviating symptoms in patients with secondary hyperparathyroidism due to chronic kidney disease, as supported by the most recent study 1.
- The choice of surgical approach may depend on the individual patient's needs and the surgeon's experience, but TPTX has been shown to have advantages over subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX + AT) in reducing the relapse of secondary hyperparathyroidism.
From the FDA Drug Label
Cinacalcet tablet is a positive modulator of the calcium sensing receptor indicated for: • Secondary Hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis. Secondary HPT in patients with CKD on dialysis (2. 2): Starting dose is 30 mg once daily. Titrate dose no more frequently than every 2 to 4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily as necessary to achieve targeted intact parathyroid hormone (iPTH) levels.
Elevated PTH can be treated with cinacalcet, as it is indicated for Secondary Hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis. The dose should be titrated to achieve targeted intact parathyroid hormone (iPTH) levels 2.
From the Research
Elevated PTH: Causes and Diagnosis
- Elevated parathyroid hormone (PTH) levels can be caused by primary hyperparathyroidism (PHPT), which is characterized by hypersecretion of PTH by the parathyroid glands 3.
- Secondary hyperparathyroidism (SHPT) is another cause of elevated PTH levels, and it can be caused by vitamin D deficiency, low calcium intake, impaired renal function, and other factors 4.
- The diagnosis of PHPT is typically made by measuring PTH levels, calcium levels, and other biochemical markers, and it can be confirmed by imaging studies such as neck ultrasound and scintigraphy 3.
Diagnostic Approach
- The diagnostic approach to an isolated elevated PTH level involves ruling out causes of SHPT, such as vitamin D deficiency and impaired renal function 4.
- A calcium load test can be used to diagnose normocalcemic PHPT, and a thiazide challenge test can be used to differentiate SHPT from normocalcemic PHPT 4.
- The diagnosis of PHPT requires confirmation of elevated PTH levels on two consecutive samples, over a 3-6 month period, and elimination of secondary causes of hyperparathyroidism 3.
Treatment and Management
- Surgical management of the hyperfunctioning parathyroid gland(s) is the only curative treatment for PHPT 3.
- Medical management of PHPT involves the use of medications to increase bone mineral density and reduce serum calcium levels, but no single drug can do both 5.
- Vitamin D supplementation has been shown to have no beneficial effect on bone mineral density or bone turnover markers after parathyroidectomy, except in patients with persistent postoperative PTH elevation 6.
Complications and Associations
- Elevated PTH levels can be associated with osteoporosis, fractures, and nephrolithiasis, and parathyroidectomy can result in an increase in bone mineral density and a reduction in nephrolithiasis 5.
- Vitamin D deficiency is common in patients with PHPT, but its effect on postoperative calcium requirements and PTH levels is unclear 7.